The home and community-based care division of Ohio Presbyterian Retirement Services, a not-for-profit provider of continuing care retirement communities and services, recently announced a partnership with Northwest Ohio ACO.
The Medicare ACO is a joint venture between the Toledo Clinic, Inc., and the University of Toledo Physicians, LLC. NW Ohio ACO helps improve coordinated care for participants as care providers work together with goals of improving quality, reducing duplication of medical services, and preventing medical errors.
Senior Independence, the home care division of Ohio Presbyterian Retirement Services, is joining forces with NW Ohio ACO to improve beneficiaries’ health with the Home to Stay care transition program, which is provided at no cost to ACO members. Home to stay care teams teach older cults how to prevent and/or manage chronic diseases. The goal is to improve care quality and reduce unnecessary health care costs.
“This partnership lets OPRS expand our proactive relationship with Toledo-area seniors. We’re there for them prior to emergency care or following a hospital stay — a time when they most need care and support,” said OPRS President and CEO Laurence Gumina in a statement. “We recognize the worthiness of providing this level of care to all beneficiaries regardless of their ability to pay.”
Home to Stay teams enter the picture when a beneficiary becomes healthy enough to leave the hospital. The team determines whether the beneficiary requires skilled home health care, and if they do, a Senior Independence home health nurse visits the home within 24 and then provides ongoing care.
If beneficiaries don’t need skilled home care, the team will explain how Home to Stay works. Through the program, a registered nurse or licensed practical nurse visits patients at their homes within 72 hours of discharge, and again seven to ten days following discharge. The nurses do thorough medication reviews and resolve issues, take vital signs, talk about personal emergency plans, establish personal health records, teach disease signs and symptoms, and confirm follow-up appointments with primary care physicians. They also make sure the patient has transportation to those appointments.
In addition to the in-home visits, a nurse or social worker calls the beneficiary three times during the next 21 days to follow up on care and wellness.
“We’re pleased to announce the relationship between our organizations. We believe this relationship will enhance quality and improve the patient experience for beneficiaries served by Northwest Ohio ACO,” says Gregory Hawkins, executive director of NW Ohio ACO.
The Home to Stay program also provides a personal emergency plan that helps seniors determine who they should call for care, whether it’s a Home to Stay nurse, the doctor’s office, or 911, and what to tell the provider in terms of signs and symptoms and medical background.
Technology and information-sharing are expected to have large roles in the partnership, according to Boyson, including the use of electronic medical records that will streamline communications, improve care, and provide data to create better outcomes and reduce costs.
Written by Alyssa Gerace